Clinical UM Guideline
Subject: Custodial Care
Guideline #: CG-MED-19 Publish Date: 01/03/2024
Status: Revised Last Review Date: 11/09/2023
Description

This document defines custodial care, a type of care that generally provides assistance in performing activities of daily living (ADL); for example, assistance walking, transferring in and out of bed, bathing, dressing, using the toilet, preparation of food, feeding and supervision of medication that usually can be self-administered. Custodial care essentially is personal care that does not require the continuing attention of trained medical or paramedical personnel.

Note: Please see the following related documents for additional information:

Clinical Indications

Care that does not meet the criteria for skilled nursing or skilled rehabilitation services is considered custodial.
Note: Not all benefit contracts/certificates include benefits for custodial services as defined by this document. Benefit language supersedes this document.

Definition of Custodial Care:

  1. Custodial care is that care which is primarily for the purpose of assisting the individual in the activities of daily living or in meeting personal rather than medical needs, which is not specific therapy for an illness or injury and is not skilled care.
  2. Custodial care serves to assist an individual in the activities of daily living, such as assistance in walking, getting in and out of bed, bathing, dressing, feeding, using the toilet, preparation of special diets, and supervision of medication that usually can be self-administered.
  3. Custodial care essentially is personal care that does not require the continuing attention or supervision of trained, medical or paramedical personnel.
  4. Custodial care is maintenance care provided by family members, health aides or other unlicensed individuals after an acute medical event, including behavioral health events, when an individual has reached the maximum level of physical or mental function.
  5. In determining whether an individual is receiving custodial care, the factors considered are the level of care and medical supervision required and furnished. The decision is not based on diagnosis, type of condition, degree of functional limitation or rehabilitation potential.

Note: Custodial care may occur in settings other than the home.

Examples of Custodial Care, include, but are not limited to, the following:

  1. Assistance in dressing, eating, and toileting;
  2. Periodic turning and positioning in bed;
  3. Prophylactic and palliative skin care, including bathing and application of creams, or treatment of minor skin problems;
  4. Stable bolus feeding by nasogastric, gastrostomy or jejunostomy tube (Note: skilled care, supervision or observation may be required if feedings are not stable);
  5. Routine care of the incontinent individual, including use of diapers and protective sheets;
  6. Routine services to maintain satisfactory functioning of indwelling bladder catheters (this would include emptying containers and cleaning them, and clamping tubing);
  7. General maintenance care of colostomy and ileostomy;
  8. General supervision of exercises, which have been taught to the individual and do not require skilled rehabilitation personnel for their performance. This includes, but is not limited to:
    1. repetitive exercises to maintain function, improve gait, or maintain strength or endurance; or
    2. passive exercises to maintain range of motion in paralyzed extremities, or
    3. assisted walking.
  9. Daily supervision and assistance with dressing, eating and hygiene for an individual with serious mental illness with findings such as cognitive impairment, delusions and hallucinations that interfere with an individual’s ability to live in the community.
  10. Changes of dressings for non-infected postoperative or chronic conditions;
  11. General maintenance care in connection with a plaster cast (skilled supervision or observation may be required where the individual has pre-existing skin or circulatory conditions or needs to have traction adjusted);
  12. Routine care in connection with braces and similar devices;
  13. Use of heat as a palliative and comfort measure, such as whirlpool or steam pack;
  14. Routine administration of medical gases after a regimen of therapy has been established (i.e., administration of medical gases after the individual has been taught how to institute therapy);
  15. Administration of routine oral medications, eye drops, and ointments (the fact that an individual cannot be relied upon to take such medications himself/herself or that state law requires all medications be dispensed by a nurse to those individuals in an institution would not change this service to a skilled service);
  16. Chronic uncomplicated oral or tracheal suctioning (Note: skilled care, supervision or observation may be required if suctioning is complicated).
Coding

Coding edits for medical necessity review are not implemented for this guideline. Where a more specific policy or guideline exists, that document will take precedence and may include specific coding edits and/or instructions. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

Discussion/General Information

Institutional care that is below the level of care covered in a Skilled Nursing Facility (SNF) is custodial care. Some examples of custodial care in hospitals and SNFs include, but are not limited to:

Definitions

Acute Medical Event (includes behavioral health events): A relatively abrupt change in condition that requires medical services, intervention(s) intended to arrest and, hopefully, reverse the condition or conditions. Stabilization can be associated with limited ability to meet basic needs, which are addressed with custodial care.

Cardiac Disorder: Condition(s) that affect heart structures or function such as: coronary artery disease, heart attack, heart failure, abnormal heart rhythms, congenital heart disease, vascular disease or heart valve disease.

Serious Mental Illness: A mental, behavioral, or emotional disorder resulting in a serious functional impairment, which substantially interferes with or limits one or more major life activities. (National Institute of Mental Health [NHMH], 2023).

References

Government Agency, Medical Society, and Other Authoritative Publications:

  1. Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual. Chapter 8. Coverage of Extended Care (SNF) Services under Hospital Insurance. Rev. 261, 10-04-19. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c08pdf.pdf. Accessed on September 7, 2023.
  2. Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual. Chapter 16. General Exclusions from Coverage. Rev.198, 11-06-14. Available at: http://www.cms.hhs.gov/manuals/Downloads/bp102c16.pdf. Accessed on September 7, 2023.
  3. Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual. Chapter 7. Home Health Services. Rev. 11447, 06-06-22. Available at: http://www.cms.hhs.gov/manuals/Downloads/bp102c07.pdf. Accessed on September 7, 2023.
  4. U.S. Department of Health and Human Services. Substance Abuse and Mental Health Services Administration (SAMHSA). Living Well with Serious Mental Illness. Last updated April 24, 2023. Available at: https://www.samhsa.gov/serious-mental-illness. Accessed on September 7, 2023.
Websites for Additional Information
  1. National Institute of Mental Health (NIMH). Mental Illness. Updated March 2023. Available at: https://www.nimh.nih.gov/health/statistics/mental-illness#part_2538. Accessed on September 7, 2023.
History

Status

Date

Action

Revised

11/09/2023

Medical Policy & Technology Assessment Committee (MPTAC) review. Revised Clinical Indications section by changing “severe and persistent mental illness” to “serious mental illness”. Reformatted bullets to alphanumeric. Updated Discussion/General Information, Definitions, References, and Websites for Additional Information sections.

Reviewed

11/10/2022

MPTAC review. Discussion, References, and Websites sections updated.

Reviewed

11/11/2021

MPTAC review. References and Websites sections updated.

Reviewed

11/05/2020

MPTAC review. References and Websites sections updated.

Reviewed

11/07/2019

MPTAC review. References and Websites sections updated.

Reviewed

11/08/2018

MPTAC review. References and Websites sections updated.

Reviewed

02/27/2018

MPTAC review. Updated header language from “Current Effective Date” to “Publish Date. References section updated.

Revised

02/02/2017

MPTAC review. Note added to Clinical Indications section. Definition of custodial care updated. Examples of custodial care updated in Clinical Indications and Discussion/General Information sections. Definition and Websites for Additional Information sections added.

Reviewed

02/04/2016

MPTAC review. References section updated.

Reviewed

02/05/2015

MPTAC review. Description and References sections updated.

Reviewed

02/13/2014

MPTAC review. Reference links updated.

Reviewed

02/14/2013

MPTAC review. Reference links updated.

Reviewed

02/16/2012

MPTAC review. Reference links updated.

Revised

02/17/2011

MPTAC review. Definition of custodial care and examples of custodial care updated in the Clinical Indication section. Discussion and Reference links updated.

Reviewed

02/25/2010

MPTAC review. Custodial care examples for stable bolus feeding and chronic uncomplicated oral or tracheal suctioning clarified. Place of Service section removed. References updated.

 

06/23/2009

Removed CG-MED-25 Hospice, Inpatient Setting from note referring to related documents as CG MED-25 has been archived.

Reviewed

02/26/2009

MPTAC review. References updated. Note under description updated with additional related document. Removed case management section.

Reviewed

02/21/2008

MPTAC review. Note added under description referring to other documents for additional information. References updated.

Reviewed

03/08/2007

MPTAC review. References updated.

Revised

03/23/2006

MPTAC review. Referenced Skilled Nursing and Rehabilitation clinical guideline and aligned definition of custodial care on both documents. 

Revised

12/01/2005

MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.

Pre-Merger Organizations

Last Review Date

Document Number

Title

Anthem, Inc.

 

None

 

Anthem Mid West

02/11/2005

MA-020

Skilled Nursing Facility Setting, Skilled and Custodial Services Defined

Anthem Mid West

02/11/2005

MA-021

Home Health Care Setting, Skilled and Custodial Services Defined for NASCO use only

WellPoint Health Networks, Inc.

06/24/2004

Definitions

Custodial Care

 


Federal and State law, as well as contract language including definitions and specific coverage provisions/exclusions, and Medical Policy take precedence over Clinical UM Guidelines and must be considered first in determining eligibility for coverage. The member's contract benefits in effect on the date that services are rendered must be used. Clinical UM Guidelines, which address medical efficacy, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Clinical UM Guidelines periodically. Clinical UM guidelines are used when the plan performs utilization review for the subject. Due to variances in utilization patterns, each plan may choose whether or not to adopt a particular Clinical UM Guideline. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the back of the member's card.

No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan.

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